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  • New Patient Registration

    Please fill in the form below


  • Vision Insurance:

    (Please fill out using the Primary Subscriber's Information)

  • Medical Insurance:

    (Please fill out using the Primary Subscriber's Information)

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  • Authorization:

    I hereby give my consent to the doctors, staff and associates of Ikeda Optometry to provide eye care services to me and / or my family. I understand and agree that I am responsible for the balance of the account. I acknowledge that by presenting myself or my child as a patient, I consent for vision and medical care by Dr. John Ikeda and the staff of Ikeda Optometry. I hereby grant full authority to Dr. John Ikeda and respective assistants to administer and perform any and all drugs, treatments, tests, or diagnostic procedures to or upon me, which may be advised or necessary.
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